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Fill and Sign the Florida Corporation 497302789 Form

Fill and Sign the Florida Corporation 497302789 Form

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CERTIFICATE OF PAYMENT TO THE CONTRACTOR- CORPORATION TO: Lienor ______________________ Lienor's Address ___________________________________________________ Contractor ___________________ Contractor's Address ____________________________________________________ Surety ______________________ Surety's Address _____________________________________________________ Under penalties of perjury, the undersigned certifies that the bond recorded with this certificate conforms with Section 713.245, F.S., that the bond is in full force and effect, and that the contractor has been paid $ _________________ for labor, services, and materials described in the Claim of Lien filed by _______________________________ dated _____ day of __________________ , 20 _____ , and recorded _____ day of ___________________ , 20 _____ , in Official Record Book __________ , Page __________ , of the Public Records of ________________ County, Florida. DATED this _____ day of ________________ , 20 ______ . Owner's Signature _________________________ Type or Print Name _____ _______________________ Title (President or Vice President) _____ _______________ Name of Corporation _____ ______________________ Owner's Address _______________________________ STATE OF _____________ COUNTY OF _____________ Sworn to (or affirmed) and subscribed before me this _____ day of _____________, 20_____ by _________________________ (name of person making statement). _________________________ NOTARY PUBLIC Print, Type or Stamp Commissioned Name of Notary Public _________________________ Commission Expires _________________________ Personally Known _________________ OR Produced Identification __________________ Type of Identification Produced _______________ Certificate of Payment to the Contractor Page 1 of 2 Contractor's Signature _________________________ Type or Print Name _____ _______________________ Title _____ ___________________________________ Contractor's Address ______________________________ Name of Corporation _____ ______________________ STATE OF _____________ COUNTY OF _____________ Sworn to (or affirmed) and subscribed before me this _____ day of _____________, 20_____ by _________________________ (name of person making statement). _________________________ NOTARY PUBLIC Print, Type or Stamp Commissioned Name of Notary Public _________________________ Commission Expires _________________________ Personally Known _________________ OR Produced Identification __________________ Type of Identification Produced _______________ Certificate of Payment to the Contractor Page 2 of 2

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